Stephen Del Giudice, MD

2019 NH Healthcare Quality and Safety Conference

May 8, 2019

BURNOUT IN HEALTHCARE:

WHY NOW? WHAT’S NEXT?

• Give an overview of burnout in healthcare and how it influences patient safety and satisfaction.

• Discuss some interventions organizations and individuals can use to prevent burnout.

• Define mindfulness and explain how it works to help prevent burnout.

WHAT I’M GOING TO TALK ABOUT TODAY

A Crisis in Health Care: A Call to Action on Physician Burnout

Partnership with the Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute, Ashish K. Jha, MD, MPH Andrew R. Iliff, MA, JD, January 2019

IF YOU READ ONE ARTICLE AFTER THIS TALK, THIS

IS IT

Physician burnout is a public health crisis that urgently

demands action by health care institutions, governing

bodies, and regulatory authorities. If left unaddressed, the

worsening crisis threatens to undermine the very provision

of care, as well as eroding the mental health of physicians

across the country.

CONCLUSION:

Source: Partnership with the Massachusetts Medical Society, Massachusetts Health and Hospital Association,

Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute, Ashish K. Jha, MD, MPH Andrew

R. Iliff, MA, JD, January 2019

• Among physicians, burnout has reached about 50%

• Prevalence of burnout among nurses is estimated to be around one third

• A Medical Group Management Association poll last year revealed burnout among healthcare leaders at 45%

BURNOUT IN HEALTHCARE: HOW BAD IS IT?

SO WHAT IS BURNOUT?

• Loss of enthusiasm at work (emotional

exhaustion)

• Treating people as if they were objects

(depersonalization)

• Having a sense that work is no longer meaningful

(what you do doesn’t really matter)

Some sobering fatigue and burnout statistics regarding nurses*

• 98 percent of hospital nurses said their work is physically and mentally

demanding

• 85 percent noted that their nursing jobs make them fatigued overall

• 63 percent reported that their work has caused nurse burnout

• 44 percent worry their patient care will suffer because they are so tired

• 41 percent have considered changing hospitals during the past year due

to burnout

WHAT NURSES ARE SAYING…

*Source: May 2017 survey by Kronos Incorporated; survey of 257 RNs working in U.S. hospitals

• Too many bureaucratic tasks (e.g. charting, paperwork)

• Spending too many hours at work

• Lack of respect from administrators/employees,

colleagues or staff

• Increasing computerization of practice (EHR)

Source: Medscape National Physician Burnout & Depression Report 2018

WHAT DOCTORS ARE SAYING…

• Conflict with the organization’s mission, vision and values.

• Limited resources and training to perform and complete work

• Lack of appropriate compensation for work.

• Broken promises by the employer.

• Lack of appreciation and recognition.

• The more you have control over what you do and how you do it,

the easier it is to mitigate against burnout.

WHAT HEALTHCARE LEADERS ARE SAYING…

Source: MGMA poll conducted on June 26, 2018, with 1,746 total responses.

Kenneth T. Hertz, FACMPE, principal, MGMA Consulting

• More negative with co-workers, especially when introduced to change

• More callous towards patients; less interested in getting to know them

• Less talkative and cheerful during team meetings or huddles• A lower threshold to become irritable with patients and staff• Making fun of your organization’s leaders and their

commitments to excellence• More self-justification to leave early, show up late, and call in

sick

SOME OF THE WARNING SIGNS OF BURNOUT

THE ELECTRONIC HEALTH RECORD IS OFTEN CITED

AS A CONTRIBUTOR TO BURNOUT IN HEALTHCARE

THE EHR

• Higher turnover rates

• Higher error rates

• Higher absenteeism rates

• Lower morale

• Lower patient satisfaction scores

• Reduction in workforce

WHAT BURNOUT DOES IN THE WORKPLACE

In this large national study, physician burnout, fatigue, and work unit

safety grades were independently associated with major medical

errors. Interventions to reduce rates of medical errors must address

both physician well-being and work unit safety.

REDUCING BURNOUT PROMOTES PATIENT SAFETY

Source: Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors.

Mayo Clinic Proceedings Nov. 2018 Tait Shanafelt, MD et al.

Overall physician burnout doubled the odds of involvement in

patient safety incidents. All three dimensions of physician

burnout—emotional exhaustion, depersonalization, and reduced

personal accomplishment—were linked to involvement in patient

safety incidents.

Source: Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction-A

Systematic Review and Meta-analysis, Maria Panagioti, JAMA Intern Med. 2018;178(10):1317-1331

This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental healthcare policy goal across the globe.

Source: Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction-A Systematic Review and Meta-analysis,

Maria Panagioti, JAMA Intern Med. 2018;178(10):1317-1331

BURNOUT AND PATIENT SAFETY

The results of this systematic literature review suggest that there is moderate evidence that burnout is associated with safety-related quality of care.

Source: The Relationship Between Physician Burnout and Quality of Healthcare in Terms of Safety and Acceptability: A Systematic Review,

British Medical Journal 2017:7(6) Carolyn S Dewa

BURNOUT AND PATIENT SAFETY

Overall physician burnout doubled the odds for low patient satisfaction. Depersonalization was linked to a 4.5-fold increased risk. The researchers also found that physicians early in their career have a higher propensity for unprofessionalism.

Source: Association Between Physician Burnout and Patient Safety, Professionalism,

and Patient Satisfaction: A Systematic Review and Meta-analysis, Maria Panagioti,

JAMA Intern Med. 2018;178(10):1317-1331

BURNOUT AND PATIENT SATISFACTION

• Impaired attention and memory• Less attention to detail• Diminished vigilance and cognitive

function• Less effective care team communication• Increased safety lapses• Increased agitation and aggressive

attitudes towards their patients, their work, or their colleagues

CYNICALLY DETACHED:DEPRESSED AND

DANGEROUS

Understanding the business case to reduce burnout and promote

engagement as well as overcoming the misperception that nothing

meaningful can be done are key steps for organizations to begin to take

action. Evidence suggests that improvement is possible, investment is

justified, and return on investment measurable.

Addressing this issue is not only the organization’s ethical responsibility, it is

also the fiscally responsible one.

Source: The Business Case for Investing in Physician Well-being,

Tait Shanafelt, MD; Joel Goh, PhD; Christine Sinsky, MD JAMA Internal Medicine Published online September 25, 2017

Source: Connecting Organizational Culture and Quality of Care in the Hospital: Is Job Burnout the Missing Link?

Montgomery, Anthony & Panagopoulou, Efharis & Kehoe, Ian & Efthymios, Valkanos. (2011). Journal of Health Organization

and Management. 25. 108-23.

• What structural or operational changes will lower stress

at work and prevent burnout?

• What personal changes can make you more resilient at

work?

WHAT CAN YOU DO?

• What can my

organization do to

help me?

• What can I do to

help myself?

NOW WHAT?

• Are individuals who

choose to work in

healthcare more

vulnerable to stress

and burnout, or has the

healthcare system

evolved into a burnout

factory?

QUESTION:

• Excessive workload

• Work inefficiency

• Work-home balance

• Loss of control

• Loss of meaning from work

PRIMARY DRIVERS FOR BURNOUT IN HEALTHCARE

ORGANIZATIONAL: reasonable limits to hours worked,

fair productivity goals, appropriate job role assignments

INDIVIDUAL: consider part-time status, make hard

decisions that balance income and productivity goals with

workplace satisfaction

EXCESSIVE WORKLOAD

ORGANIZATIONAL: optimize electronic medical records,

shift clerical work to non-clinical staff, provide cheerful

assistance to meet regulatory requirements

INDIVIDUAL: prioritize and delegate tasks appropriately,

be open to process improvement recommendations

WORK INEFFICIENCY

ORGANIZATIONAL: support flexible work schedules,

acknowledge when required work tasks cannot be performed

during assigned work hours, reduce clinicians time on the

EHR outside of assigned work hours

INDIVIDUAL: keep your eyes on your North Star: remind

yourself regularly of life priorities and maintain self-care

WORK-HOME BALANCE

ORGANIZATIONAL: promote physician and staff

leadership and shared decision-making, establish work

requirements with employee engagement

INDIVIDUAL: attend resiliency training program and

practice mindfulness

LOSS OF CONTROL

ORGANIZATIONAL: promote core values (walk the talk), offer

peer support, maximize patient time with clinicians, foster

employee communities (commensality), provide professional

development opportunities

INDIVIDUAL: embrace positive attitudes (reframing,

appreciative inquiry), share work experiences with colleagues

(narrative medicine), practice mindfulness

LOSS OF MEANING FROM WORK

SO WHAT IS MINDFULNESS ANYWAY?

“Mindfulness means paying attention in a

particular way, on purpose, in the present

moment, and non-judgmentally.”

(Jon Kabat-Zinn)

• The roots of mindfulness are found in two ancient religions:

• Hinduism, which arose in what is now Pakistan, over 4,000 years ago

• Buddhism, founded around 450 B.C.E. in northern India by Siddhartha Gautama (later referred to as the Buddha)

• After World War II, East and West met:

• The study of comparative religions

• The travel of mediation teachers to the US

• Intellectual leaders in the West study mindfulness

THE HISTORY OF MINDFULNESS IN AMERICA

• Jon Kabat-Zinn started the Mindfulness-Based Stress Reduction (MBSR) program in 1979-U Mass. Medical Center.

• Inspired by MBSR success, Mindfulness-Based Cognitive Therapy (MBCT) developed in the 1990's to treat depression.

• Recently Judson Brewer and others have studied the neuroscience of mindfulness.

• Thousands of years ago, practitioners of mindfulness somehow recognized its transforming power to quiet the mind--now modern science has confirmed their understanding.

OUR HISTORY LESSON (CONTINUED)

• What we call meditation has transformed into a safe, easy, inexpensive way to help treat many of the diseases related to stress (anxiety, depression, insomnia, addiction, chronic pain, hypertension) and other medical conditions.

• Our interest today is how it can help people who work in healthcare manage the expected stress and mental strain of doing this hard work.

MINDFULNESS AS HEALTHCARE

Our study suggests that

mindfulness training produces

an improvement in three

capacities that are key for

successful leadership in the

21st century: resilience, the

capacity for collaboration, and

the ability to lead in complex

conditions.

MINDFULNESS AND LEADERSHIP

Source: How to Bring Mindfulness to Your Company’s Leadership

Megan Reitz, Michael Chaskalson, Harvard Business Review. December 1, 2016

• The leaders in our study became less reactive and more

responsive, which in turn affected many other skills, such

as regulating their emotions, empathizing with others,

focusing more readily on issues at hand, adapting to the

situations they found themselves in, and taking broader

perspectives into account.

• One leader summed up what this meant: “I now have

moments of choice that I didn’t have before.”

MAINTAINING MENTAL EQUILIBRIUM

Source: How to Bring Mindfulness to Your Company’s Leadership

Megan Reitz, Michael Chaskalson, Harvard Business Review. December 1, 2016

Mindfulness weakens

automatically activated

associations

REMEMBER TO LISTEN WHEN YOU LISTEN

Source: Mindfulness Meditation Reduces Implicit Age and Race Bias:

The Role of Reduced Automaticity of Responding

Adam Lueke, Bryan Gibson First Published November 24, 2014 Social

Psychological and Personality Science

The McMindfulness Craze: The Shadow Side of the

Mindfulness Revolution. Jeffrey B. Rubin, Truthout. January

4, 2015

McMindfulness- The Marketing of Well-Being. June13, 2014.

Straight Talk Jeremy D. Safran Ph.D.

• So what is McMindfulness? It’s the

marketing of mindfulness practice as a

commodity that is sold like any other

commodity in our brand culture.

THE RISE OF MCMINDFULNESS

• We know what mindfulness is (sort of).

• We know it can be used to ease mental stress as well as to prevent and treat burnout.

• We know practicing mindfulness improves listening skills and cultivates a responding rather than a reacting mind.

• But how does it work?

LET’S PAUSE HERE

Default Mode Network (DMN)

• Rumination

• Day dreaming

• Mind wandering

Task Positive Network (TPN)

• Attention focused

• Engaged

• Awareness

EVOLUTIONARY BIOLOGY OF THE BRAIN

Default Mode Network

• When our minds have no compelling physical or mental anchor (in the present) we easily slip into this mode.

• We “default” from reality into daydreaming.

• Our thoughts are free floating and unstructured. The roaming mind. Also called the monkey mind. The “movie mind.”

Task Positive Network

• When we concentrate or bring our attention to a physical motion or sensation, or to a specific mental task, we engage TPN, and naturally pull out of the DMN.

• Mutually exclusive operations

• You will always be in one or the other—you cannot be in both modes simultaneously

Default Mode Network….

Task Positive Network….

• The DMN consists of four parts of the brain: amygdala, hippocampus, posterior cingulate cortex (PCC), and medial prefrontal cortex (mPFC)

• The TPN consists of another four neurological structures: insula, somatosensory cortex, anterior cingulate cortex (ACC), and dorsolateral prefrontal cortex (dlPFC)

THE NEUROANATOMY OF CONSCIOUSNESS

• Functional magnetic resonance imaging (fMRI), (records pictures and brain activity) show brain changes occurring when a person is meditating.

• Changes in brain activity, in subjects who have learned to meditate, hold steady even when they’re not meditating.

• During meditation:

• The amygdala is less activated. (Responsible for the response to and memory of emotions, especially fear.)

• The dorsolateral prefrontal cortex is more activated. (Controls executive function and self-regulations skills: working memory, mental flexibility, and self-control including resisting impulsive actions or responses. )

WATCHING THE BRAIN DURING MEDITATION

FUNCTIONAL MRI DURING MEDITATION

• We live in a DMN dominated state of mind when not engaged in

captivating activities

• This can lead to anxiety, depression, and an exaggerated self-referential

view of reality

• The practice of mindfulness and other forms of meditation help to

recalibrate the natural push-and-pull between the DMN and TPN.

• How? Simply by coming back to TPN during activities that frequently

seduce us into DMN.

• Engaging our TPN causes the DMN, and its attendant regrets of the past

(depression) and fear of the future (anxiety) to vanish in an instant.

MINDFULNESS AND THE DMN-TPN BALANCE

• The default mode network, an evolutionary tool that

helped us plan and learn from experience, has reached

unhealthy dominance in a brain with increased mental

capacities

• Neither the DMN or TPN is good or bad; it’s the balance

that counts. Mindfulness keeps the DMN in check and

prevents the overkill of worry and self-blame

MINDFULNESS: REBALANCING THE DMN AND TPN

(“HACKING INTO THE DMN”)

MINDFULNESS HELPS US RESTORE MENTAL

BALANCE

• Today, excessive and compulsive attention to thoughts that arise during the DMN can lead to mental distress: anxiety and depression.

• Mindfulness helps restore the balance between the DMN and the TPN —to keep us sane.

• Training programs

• Books and audio programs

• Apps

GETTING STARTED

• Headspace• 10% Happier • Smiling Mind • Calm • imindfulness • Buddify 2 • Complete Mindfulness • Mindfulness Daily • Simply Being• Stop, Breath, and Think

• Best Way to Start: Today

POPULAR MINDFULNESS APPS

I’ve lived through some terrible things in my life,

some of which actually happened.

WHAT I LEARNED FROM MEDITATION

Mark Twain

Safe and effective patient care

starts with caring for the caregiver.

www.northernskyhealthcareconsultants.com

Stephen Del Giudice, MD